1. (Otitis Media (AAP/AAFP
Dr. Faisal Al Hadad
Consultant of Family Medicine
& Occupational Health
PSMMC

2. Definitions

AOM is a viral or bacterial infection of the middle ear.
By age three, more than 80 percent of children have
been diagnosed as AOM.

Otitis media with effusion is middle ear effusion in
the absence of acute infection.

Chronic suppurative otitis media is persistent
infection and resultant perforation of the tympanic
membrane.

4. Pathophysiology

An allergy or URTI causes obstruction of the ET which results in
accumulation of middle ear secretions (effusion).

Secondary bacterial or viral infection of the effusion causes
suppuration and features of AOM.

The effusion may persist for wks or months after the infection resolves.

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis are the most common bacterial isolates from the middle ear
fluid of children with AOM.

Penicillin-resistant S. pneumoniae is the most common cause of
recurrent and persistent AOM.

5. Diagnostic criteria for AOM

Rapid onset of symptoms
and

Middle ear effusion (bulging TM, limited or absent mobility of
membrane and air-fluid level behind membrane)
And

Signs and symptoms of middle ear inflammation (erythema of TM
and otalgia affecting sleep or normal activity)

6. AOM
Non-specific symptoms of AOM:
 Fever,
 Headache,
 Irritability,
 Cough,
 Rhinitis,
 Listlessness,
 Anorexia,
 Vomiting,
 Diarrhea

7. (Otoscopy (acute otitis media

8. Tympanometry: A flattened tracing (type B
tracing( indicating middle ear effusion

9. Chronic supportive otitis media
Chronic suppurative otitis media presents with persistent or
recurrent otorrhea through a perforated TM.

10. Treatment of AOM

Treatment goals in AOM include symptom resolution
and reduction of recurrence.

Most children with AOM have spontaneous resolution
within seven to 14 days; therefore, antibiotics should
not routinely be prescribed initially for all children.

Delaying antibiotic therapy in selected patients
reduces treatment-related costs and side effects and
minimizes emergence of resistant strains.

11. (Treatment AOM (Symptomatic

Pain management is important in the first two days
after diagnosis.

Acetaminophen (15 mg/kg every four to six hrs) and
ibuprofen (10 mg/kg every six hrs)
.

12. (Treatment AOM (antibiotics

Antibiotics are recommended for all children younger than
six months, for those six months to two years of age
when the diagnosis is certain.

All children older than two years with severe infection
(defined as moderate to severe otalgia or temperature
greater than 39° C.

13. (Treatment AOM (antibiotics

High-dosage amoxicillin (80 to 90 mg/kg/day BD for 10
days) is recommended as first-line antibiotic therapy in
children with AOM.

In children older than six years with mild to moderate
disease, a five- to seven day course is adequate.

First-line treatment with amoxicillin is not recommended
in children with penicillin allergy.

14. (Treatment AOM (antibiotics

Cephalosporins may be used in children allergic to
penicillin if there is no history of urticaria or anaphylaxis to
penicillin.
If there is a history of urticaria or anaphylaxis to penicillin.
, a macrolide (e.g., azithromycin, clarithromycin) or
clindamycin may be used.


A single dose of parenteral ceftriaxone (50 mg per kg)
may be useful in children with vomiting or in whom
compliance is a concern.

15. Treatment of persistent AOM

If there is no clinical improvement within 48 to 72 hours, initiate
antibiotic therapy in those on symptomatic treatment alone. Patients
who are already taking antibiotics should be changed to second-line
therapy.

Second-line therapy include high-dose amoxicillin/clavulanate,
cephalosporins, and macrolides. Parenteral ceftriaxone administered
daily over three days is useful in children with emesis or resistance to
amoxicillin/ clavulanate.

For children who do not respond to second-line antibiotics, clindamycin
and tympanocentesis are appropriate options.

CT is useful if bony extension is suspected. MRI is superior to CT in
evaluating potential intracranial complications.

16. Treatment of recurrent AOM

Most children with recurrent AOM improve with watchful
waiting.

Although antibiotic prophylaxis may reduce recurrence,
there are no widely accepted recommendations for
antibiotic choice or prophylaxis duration.

Minimizing risk factors (e.g., exposure to cigarette smoke,
pacifier use, bottle feeding, daycare attendance)
decreases recurrence.

17. Treatment of OM with effusion

Persistent middle ear effusion after resolution of AOM requires
only monitoring and reassurance.

Children older than two years who have otitis media with effusion
must be seen at 3-6 month intervals until effusion resolves.
Children with hearing loss of 40 dB or more should be referred for
surgery.

Tympanostomy with ventilation tube insertion is the preferred
initial procedure.

Adenoidectomy may be considered in children who have
recurrent otitis media with effusion after tympanostomy if chronic
adenoiditis is present or if adenoidal hypertrophy causes nasal
obstruction.

18. Treatment of chronic suppurative OM

Topical antibiotics (e.g., quinolones, aminoglycosides,
polymyxins) are more effective than systemic antibiotics in
clearing the infection in patients with chronic suppurative otitis
media.

Oral or parenteral antibiotics are useful in patients with
systemic sepsis or inadequate response to topical antibiotics.
They should be selected on the basis of culture and sensitivity
results.

Tympanoplasty is an option in patients with chronic perforation
and hearing loss.

Mastoidectomy is often recommended for patients with chronic
mastoiditis.

19. Thank you